Self-Assessment Process

Once a practice or facility has received permission to operate, the DR must annually self-assess. It is the vision of the Practice Facility Accreditation Committee (PFAC) that annual Self-Assessments will ensure all facilities are continually in compliance with the Accreditation Standards.

It is unduly burdensome to expect all practices to have a yearly physical inspection. Yet, long intervals between inspections do pose a problem in motivating the Designated Registrants (DR) of some facilities to remain current with respect to the Accreditation Standards. Instituting a yearly, mandatory Self-Assessment is a means for the CVBC to encourage practices to maintain current facility standards, without the burden of annual on-site inspections. The backbone of this process is accurate and timely completion the self-assessment form. As a result, facilities should be very well prepared at any time for physical inspection. The self-inspection process can be viewed as a tool for the DR to determine the “health” of their practice facility from year to year.

If the self-assessment process is adhered to, mandatory on-site inspection by a practice inspector should be a quick and painless process. There is no direct fee for Self-Assessment. Each DR will be charged a fee for a physical facility inspection at the time of the facility inspection. There is no change from previous inspection cycles in this regard.

The PFAC encourages the DR to complete their Self-Assessment early in the year and forward the Annual Declaration page to the CVBC office at any time, as long as it is received by the office no later than January 31st of the following year. Completing the Self-Assessment report early will facilitate any self-assessed deficiencies being corrected by the DR should a physical inspection take place.

The DR of a practice facility that does not complete a self-assessment form, or does not submit an Annual Declaration Form by January 31st may be subject to a late filing fee of 25% of inspection fee (see Schedule C). Further, the bylaws, s. 3.8 (2), ‘Late or Failed completion or submission of a self-assessment form’ states: If a designated registrant who is deemed to owe a self-assessment late filing fee pursuant to subsection (1) fails to complete a self-assessment form or fails to submit an annual declaration form by February 28th, or fails to pay the self-assessment late filing fee by February 28th or fails to do both, the committee or the registrar has the discretion to: (a) direct an inspector to undertake an on-site inspection of that designated registrant’s practice or facility, with the full cost of the inspection payable by the designated registrant, and (b) initiate a complaint against the designated registrant under section 50 of the Act.

Notes

All practices, including satellite practices, need to self-assess.

A physical practice inspection occurs independently of the annual Self-Assessment (i.e. a Self-Assessment must be performed, and an Annual Declaration Form must be submitted even in years when a physical practice inspection occurs).

The ‘Annual Declaration’ and the rest of the completed Self-Assessment form is to be kept in the practice until requested by the inspector for review (until the next inspection cycle). Not having the completed SA forms available for the inspector during an inspection will be seen as a deficiency.

Failure to comply with the Self-Assessment process by January 31st may trigger a physical inspection at the expense of the DR.